Archive for the ‘Maternal Quality Improvement’ Category

Series: Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers

November 10th, 2015 by avatar

By Pamela Vireday

“CBAC mothers have powerful lessons to teach, if you are willing and able to hear us.”  — Melek Speros

CBAC part 2We continue our current series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Today, Pamela examines the limited research available and part three (on Thursday) will provide information on how to support CBAC women in the absence of published research.  We will also conclude the series with a useful resource list to share with the families you may work with who find themselves in this situation.  You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.


In Part One of the series – Supporting Women When a VBAC Doesn’t Happen, we discussed how women who work for a VBAC but end up with a cesarean have a unique grief that is different from that of a mother who has a primary cesarean or who chooses to have a repeat cesarean.

There is a pressing need for better support for CBAC mothers, but often birth professionals and family members have no idea how to go about offering this support. Does research have any insight on improving CBAC support to these women?

CBAC Research

Unfortunately, there has been very little research done on CBACs. Most VBAC-related research deals with VBAC rates, complications, cost-effectiveness, or the woman’s decision-making process. Women who choose VBAC but don’t end up with one are largely ignored in academic studies.

However, there are a few studies with implications for the CBAC mother, including those that address physical recovery and a few that address emotional recovery.

Physical Recovery

Most CBAC research focuses on physical morbidity, which can certainly have an influence on how a woman feels after a CBAC.

Although most CBAC mothers recover just fine, women who have a trial of labor cesarean do have higher rates of infectious morbidity, postpartum hemorrhage, hysterectomy, blood transfusions, and neonatal morbidities (El-Sayed 2007, Hibbard 2001, Durnwald and Mercer 2004).

One study found that 2.1% of women with a trial of labor experienced major maternal morbidity (Scifres 2011). How much more complicated is emotional recovery if the mother is also dealing with the aftermath of a serious infection, a sick baby, surgical injuries to nearby organs, anemia from a major hemorrhage, or heaven forbid, a uterine rupture, hysterectomy, or stillbirth?

The lesson here is that some mothers will be dealing not only with the disappointment of CBAC, but also with significant physical fallout afterwards. This can greatly complicate emotional processing, but sadly, these are often the mothers who receive the least emotional support afterwards. It’s as if their complications have made them toxic to the birth community because their experiences represent the rare worst-case scenarios no one wants to acknowledge.

The first step in helping a CBAC mother is to help her focus on her physical recovery, especially if there have been complications, even as you help her explore her emotions around the CBAC.

Emotional Recovery

There is only a small amount of research available on the emotional impact of CBACs. How do women feel about the CBAC experience? Do they regret having tried for a VBAC? Would they want to try again? What can be done to help women process the experience emotionally?

One study surveyed CBAC mothers.(Chigbu 2007) Not surprisingly, they found CBAC mothers, particularly those with no previous vaginal birth experience, often had feelings of:

  • Dashed expectations
  • Inadequacy as a mother
  • Frustration of experiencing the pain of both labor and surgery

Some women experience long-lasting trauma from birth. Although many people have written about Post-Traumatic Stress in childbirth, it is unclear from the research what the most effective approach is for dealing with PTSD in birth.

Some research indicates that Eye Movement Desensitization and Reprocessing treatment (EMDR) can be helpful (Sandström 2008, Stramrood 2012). However, research trials have been extremely small and limited in the childbirth field.

A recent Cochrane review (Bastos, 2015) concluded that there was little high-quality evidence for or against using debriefing interventions to prevent psychological trauma after childbirth. Still, many women find counseling helpful after a traumatic birth, and EMDR helpful if flashbacks are frequent or intrusive.

From anecdotal evidence, anger is a common theme among some CBAC mothers. They may be furious with care providers who let them down, with the seemingly random nature of birth fortunes, or with their bodies for “not working right”:

It was very important to me that someone recognize and validate my anger. I was SO FREAKING ANGRY!!!!! And I needed to hear, “You have every right to your anger!”    – Jer 

This kind of anger is uncomfortable for birth professionals to hear. We want women to have happy endings and just be enthralled with their babies. But denying anger doesn’t make it go away; it just makes it burrow down more destructively. Helping a mother speak her anger without taking it personally vents it and takes away some of its toxicity so that healing can start to take place.

Many CBAC mothers deal with a strong sense of shame and failure, of feeling broken. Health care providers make this worse when they blame women by telling them their pelvises are “too narrow,” their cervix is “horrible,” or that they have “too much soft tissue” around their vaginas. Health care providers must be careful in issuing judgments such as these because many women told these things have gone on to have vaginal births. More often it’s a case of “this baby, this birth, this time” didn’t work, not that the woman’s body is defective.

Some CBAC mothers obsess over the “what-ifs” of birth decisions or spend a lot of time analyzing what went wrong. This can be a way of asserting a sense of control over what feels uncontrollable. Analysis can sometimes be useful, but it also can lead to a never-ending rabbit hole of self-blame. Sometimes we just don’t know why birth turns out the way it does, and it can help when health care providers and birth professionals share this.

“Pregnancy/childbirth is one of the most unfair endeavors I’ve encountered. Realizing that has set me free in a way. If something as commonplace as childbirth has so many variations even despite what is actively chosen/done, then how can anything else in our lives go the way we want if we just. work. hard. enough. Life isn’t fair. Childbirth, the ease for some, the struggle for others, just isn’t fair. And that’s been liberating for me.”  – L  

Common Recovery Arcs

Recovery from a CBAC can be an emotional roller-coaster. Many women experience ambivalent feelings and these feelings can change considerably over time.

Immediately after a CBAC, some women are so traumatized that they need to process it immediately. Yet the people around them may feel threatened by any negative feelings around the birth; they don’t understand that women can love their babies but still feel upset about how the baby arrived.

Some CBAC women find a place of temporary peace about the experience. They may be reconciled to its necessity, or may simply need to focus first on the baby and put aside any other feelings. It may only be later that more ambivalent feelings rise up and must be dealt with.

Sometimes right after the birth, women wish they had just chosen a planned repeat cesarean. However, with time, this feeling changes for many CBAC women. One study found that, while women were disappointed at not having a VBAC, 92% of CBAC women “were pleased that they had attempted a vaginal birth” (Cleary-Goldman, 2005). The authors concluded that “Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome.”

This result was also found by Phillips (2009). Indeed, Chigbu (2007) noted, “This survey revealed that most women still would prefer to be delivered vaginally after 2 previous cesarean deliveries.”

What few surveys have been done show the emotional impact a CBAC can have, but the topic is glaringly understudied. More research is urgently needed on the experiences of CBAC mothers and what can be done to help support them.

In the absence of research to guide us, we must trust what CBAC women tell us they need. More on that in Part Three of the series on Thursday.


Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for the prevention of psychological trauma in women following childbirth. Cochrane Database Syst Rev. 2015 Apr 10;4:CD007194. doi: 10.1002/14651858.CD007194.pub2. PMID: 25858181

Chigbu CO, Enwereji JO, Ikeme AC.  Women’s experiences following failed vaginal birth after cesarean delivery. Int J Gynaecol Obstet 2007 Nov;99(2):113-6.   PMID: 17662288

Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN. Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.  Am J Perinatol. 2005 May;22(4):217-21.  PMID:15906216

Durnwald C and Mercer B.  Vaginal birth after Cesarean delivery: predicting success, risks of failure. J Matern Fetal Neonatal Med 2004 Jun;15(6):388-93.  PMID:15280110

El-Sayed YY, Watkins MM, Fix M, Druzin ML, Pullen KKM, Caughey AB.  Perinatal outcomes after successful and failed trials of labor after cesarean delivery. American Journal of Obstetrics and Gynecology 2007 Jun;196(6):583.e1-5; discussion 583.e5.  PMID: 17547905

Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity.  American Journal of Obstetrics and Gynecology.  2001 Jun;184(7):1365-71; discussion 1371-3.  PMID: 11408854.

Phillips E, McGrath P, Vaughan G.  ‘I wanted desperately to have a natural birth’: Mothers’ insights on Vaginal Birth After Caesarean (VBAC).  Contemporary Nurse 2009 Dec-2010 Jan:34(1):77-84. PMID: 20230174

Sandström M, Wiberg B, Wikman M, Willman AK, Högberg U. A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth. Midwifery. 2008 Mar;24(1):62-73. Epub 2007 Jan 12. PMID: 17223232

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA.  Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section.  Am J Perinatol 2011 Mar;28(3):181-6. PMID:  20842616

Stramrood CA, van der Velde J, Doornbos B, Marieke Paarlberg K, Weijmar Schultz WC, van Pampus MG. The patient observer: eye movement  desensitization and reprocessing for the treatment of posttraumaticstress following childbirth. Birth. 2012 Mar;39(1):70-6. doi: 10.1111/j.1523-536X.2011.00517.x. Epub 2011 Dec 19. PMID: 22369608

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


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Meet Jennie Joseph, LM, CPM – Lamaze/ICEA 2015 Conference Plenary Speaker

September 10th, 2015 by avatar
© Jennie Joseph

© Jennie Joseph

Today on Science & Sensibility, we have the opportunity to meet our final Lamaze/ICEA 2015 plenary speaker- Jennie Joseph, LM, CPM.  This British born midwife is the founder and executive director of Florida’s Commonsense Childbirth Inc. whose vision states “We believe that all women deserve a healthy pregnancy, birth and baby!” Jennie is also the creator of the The JJ Way® which has been remarkably effective at reducing disparities and improving outcomes for both women and babies. Jennie owns a birth center in West Orlando, FL. She also operates a midwifery school as well as certifications for a variety of birth professionals  Jennie will be closing the conference with her plenary session: The Perinatal Revolution: Reducing Disparities & Saving Lives Through Perinatal Education. What role do childbirth educators like you play in improving outcomes for families of color?  Today, Jennie speaks a bit about this topic in advance of her presentation at the conference.  I have had the pleasure of hearing Jennie speak several times in recent years, and I know that conference attendees are in for a treat.  For more information about this year’s conference, head to the 2015 Lamaze/ICEA Conference website.

Sharon Muza: What role do childbirth educators play in helping to reduce the disparities that exist in pregnancy, birth and newborn/infant outcomes for women of color?

Jennie Joseph: Today’s educators can play an essential role in reducing disparities simply by educating themselves about what those statistics are, what they represent, who they represent and why. Once an educator understands the extent and the cause of the problem he/she is able to really embrace the need to reach women and families in meaningful and practical ways – ways that will ultimately make an impact on the outcome.

SM: What changes have you observed over time in the perception of the value of childbirth education in the communities you work with?

JJ: I think that in every community in this country there is and has been a movement away from the traditional childbirth classes of the past. Women and their partners are busy and overwhelmed, with a false sense of security engendered by internet searches and with the hope that someone else, or some other entity will take care of everything when the time comes.

SM: Why do you think that many families are not attending childbirth classes in their communities? Is it lack of offerings? Cost? Accessibility? Do new families feel it is irrelevant to their experience?

JJ: When families are disenfranchised in so many other ways there is little value seen, or interest in an additional expense, or reaching for non-existent support, given that time is at a premium and resources are low. The institutionalization of birth inherently leaves one believing that the system is already set in stone, that the options and opportunities for autonomy and independence are not going to be available, and the benefit of doing the required hours of class are not likely to avail much as far as having any say at all. Cost and accessibility may be a factor for low socio-economic communities but more importantly the fact that few independent educators are open to the outreach and innovative thinking that is needed to engage new families, leaves a void which does not appear likely to be filled anytime soon.

SM: What can Lamaze International do to support and encourage people of color to become childbirth educators and be prepared to offer evidence based programs in their communities?

JJ: Childbirth education organizations that recognize and acknowledge the inequities in perinatal health and outcomes, and that are committed to that change, will lead the way in recruiting, training and retaining a diversity of educators. Cultural humility and practical support, not only for the communities themselves, but the providers and the educators that service them typically is what is needed. Supporting from a grass-roots perspective and embracing the dedicated entry-level or non-credentialed perinatal workers and volunteers who are on the ground already will provide a pipeline to further grow the ranks of educators and practitioners able to make a difference.

SM: You have been actively involved in birth work and supporting families for many years. What keeps you from getting discouraged about the slow progress we are making in reducing preterm births, low birth weight babies, maternal complications amongst families of color.

Jennie Joseph with clientJJ: I often feel overwhelmed with the glacial changes that occur and wondered how you continue to make progress and change lives in the face of often discouraging news. I get very discouraged working with families that are disenfranchised in one way or another. I find myself sometimes at my wits end because the agreement that we have in the United States is that we just don’t know the reason why we have such a high prematurity rate and in working in my field and doing the things that I do, the way that I do them, I have been able, as have many others, to not only reduce but all but eradicate prematurity in a population of women who are considered to be at highest risk for prematurity. Low birth weight babies, complications for the mothers, maternal morbidity and mortality is rampant inside African-American communities in particular. So, how I keep from getting totally discouraged is the fact that in seeing the change brought about by applying some very simple and essentially easily applied tenents to how I provide the maternity care that we offer, we have been able to turn the tide. I know that other people are willing and are doing the work the same way. I know that they are seeing the results the same way, so I continue to hope that there will be a turning of the tide that more and more practices and practitioners will embrace these few simple steps and show that they too believe we can stop the scrounge of prematurity and low birth weight in the United States.

SM: What are you looking forward to most about being a plenary speaker and presenting to the Lamaze/ICEA 2015 conference attendees?

JJ: I am very excited about being able to present at Lamaze/ICEA 2015. I am more than thrilled. This is something that has been on my heart for a long time and I am really clear that until we embrace and involve all the perinatal team in the work at hand we will not be successful. I think that childbirth educators have a pivotal role to play in bringing about change and I know there is an openness and a willingness to hear about new and innovative ideas as far as providing that education across the board. This is an awesome opportunity for me and I am very much looking forward to it.


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Meet Elan McAllister – Lamaze/ICEA Conference Plenary Speaker

September 8th, 2015 by avatar

ElanMcAllister head shot-220x220The countdown to the Lamaze/ICEA 2015 Conference in Las Vegas is in single digits and the excitement is building. I recently had an opportunity to interview plenary conference speaker Elan McAllister, founder of Choices in Childbirth, an education and advocacy group for pregnant people and their families.  Elan will be opening the conference with her plenary session “No Day But Today” and I am very excited to hear her presentation as she shares how we all can make a difference in birth outcomes and experiences for parents and babies.  Still time to register if you have the flexibility to join us in Las Vegas.  A joint Lamaze International/ICEA conference means great networking opportunities, plenty of continuing education and two great organizations coming together to collaborate on the things that matter.

Sharon Muza: You have long been involved in theater and then went on to found Choices in Childbirth. Do you see any commonalities between a theater production and a birth? In the way one prepares for both? In what is needed to be “successful” in both?

EMc: There are so many similarities! Essentially, both are acts of creation. My role (and its been my honor) in both theater and birth has been to hold space for creation to unfold. Bringing something new into the world, whether a new life or a work of art, challenges us in remarkable ways. It takes tremendous courage to let your self be vulnerable to the creative process and I believe that no one should do it alone. As a producer, I have supported artists and encouraged them to believe in themselves and connect with their voice and vision.   As a doula, I have supported women and encouraged them to own their power in birth.

SM:  I have had the deepest respect for Choices in Childbirth and have so appreciated their invaluable consumer booklets that have been a part of my client and student information packets for many years. Can you share some of the feedback you have gotten from both consumers and professionals regarding their value?

EMc: Thank you so much and I’m thrilled to hear that the Guide to a Healthy Birth has been useful to you! Over the years we’ve distributed thousands of Guides all across the country and have had the most remarkable feedback. Women have told us that it opened a door and encouraged them to think more deeply about their birth choices. Many have referred to it as their birth bible. We worked really hard to create something that would be useful to any woman who picked it up – regardless of her birth choices. We wanted to create something that would be respected by the birth community but that could be embraced by the mainstream. I think we succeeded in that goal and it truly warms the heart to know that something you’ve created has made a difference to people.

choices in childbirth logoSM: Choices in Childbirth has been a leader in maternity care reform and has long been committed to consumer education. The CiC organization along with other maternal-infant health advocates have consistently raised their voices to help improve outcomes for mothers and babies in our country. When you look at all of the programs that CiC has had a hand in, can you share what has made you the most proud? What has been the most challenging?

EMc: Thank you for this opportunity to reflect on the work that CiC has done over the last 12 years and to feel profound gratitude to all of the people who have contributed to CiC’s successes. When you’re in the middle of things, you sometimes lose perspective, so I am grateful for this chance to reflect. In this moment, I’m most proud of the work we did last year to petition the city to reopen the labor and delivery services at North Central Bronx Hospital (NCBH).   For over 30 years, NCBH provided high quality, teamed-based midwifery care to an at risk population in the Bronx. Women who were used to an impersonal, clinic-based health care experience received personalized and continuous care at NCBH with midwives that they were able to build relationship and trust with. While cesarean section rates were skyrocketing all across the city and the nation, NCBH maintained a c-section rate of about 17%, largely due to the fact that 85-90% of births there were attended by midwives. When the services were suddenly closed in 2013, CiC joined a coalition of community organizers that worked together for nearly a year to demand not only that L&D services be returned to the community, but that the midwifery program be returned in tact. Together with local community members and organizations, we were able to make such a compelling argument to the city that they not only reopened the services but invested a million dollars in upgrading the facility!

SM: How do you think childbirth educators can help families to understand the family’s critical role and rights in shared decision-making and informed consent?

EMc: This is such a challenge. We are all faced with the frustrating reality that a huge percent of birthing families are scared about birth and feel most comfortable turning the experience and power over to the “experts.” Negative reinforcement in the form of, say, warning them about the routine overuse of unnecessary medical interventions will typically shut them down further. I have found that the most effective way to encourage families to be more engaged in the decision making process is to inspire them.   Fear of birth is prevalent in our culture and fear shuts us down. The only way to overcome that fear is to awaken families to the deep, essential truth that birth is a sacred, powerful and profoundly important life experience. Be the voice of awe and wonder that inspires them to show up fully and take a higher level of interest and responsibility for this miraculous event in their lives.

Elan McAllister and NCBH Midwives at L&D re-opening

Elan McAllister and NCBH Midwives at L&D re-opening

SM:  If a childbirth educator wanted to spend time (or increase their current level of involvement) in the birth advocacy role – what do you suggest they consider doing on both a local and on a national level? How could they get effectively get involved?

EMc: I love this question and I will be talking a lot about this at the conference. There is both inner and outer work that needs to happen in order for childbirth educators, (and all birth workers) to better engage in birth advocacy work. The inner work consists of two important shifts – 1) Step into the role of Consumer Advocate. Recognize that you are in a critical and powerful position to amplify the voices of the women and families that you are in direct contact with and 2) Become a Bridge Builder. If we’re going to have an impact on the system we must let go of the “us vs. them” victim mentality and start building relationships with decision makers.

The Affordable Care Act offers countless opportunities for us to engage and impact health care reform.   I’ll be talking more at the conference about how to take advantage of this important moment as well as providing examples of work that CiC has been doing over the last couple of years.

SM:  What are the three most important things that families can do to help ensure that their birth experience is both safe and healthy as well as positive?

EMc:  1) Be well informed and in touch with your desires and beliefs so that you can create and communicate a clear vision for your birth.

2) Choose the provider, setting and birth team that will give you the best opportunity to realize the birth that you’ve envisioned.

3) Let go and surrender.   Trust that you have done all that you can, you are stepping into a divine mystery that cannot be controlled and that will unfold exactly as it is meant to.

SM: Can you share a little about how you made the switch from theater producer to tireless advocate for families during their childbearing years? Were you always drawn to birth and birth advocacy and women’s rights? Or was that a “role” you grew into after experiencing specific events in your life?

EMc: I became involved with both theater and birth at around the same time, about 20 years ago. My early career as a professional dancer lead me to theater production right around the time that the young feminist in me picked up a book on midwifery and had her mind blown! I juggled these two passions/ straddled these two worlds for about 15 years before retiring from producing 5 years ago. Though I turned Choices in Childbirth over to new leadership last Fall, I remain devoted to my calling in service of women, babies and families.

SM:  What are you looking forward to most about being a plenary speaker and presenting to the Lamaze/ICEA 2015 conference attendees?

EMc: It’s always a pleasure to speak to a receptive, well informed audience! I look forward to sharing ideas and learning from my peers.

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Report Finds Widespread Global Mistreatment of Women during Childbirth

July 2nd, 2015 by avatar
© Pawan Kumar

© Pawan Kumar

The journal PLOS Medicine published a research review yesterday, “The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Method Systematic Review” (Bohren, et al, 2015).  Reading this report was both disturbing and extremely sad to me. Respectful care is a part of the United Nations Millennium Development Goal Target 5A: Improve Maternal Health. – which set a goal of reducing the maternal mortality ratio (the number of deaths among women caused by pregnancy- or childbirth-related complications (maternal deaths) per 100,000 live births) by 75% from 1990 to 2015.  The target rate had been 95 pregnancy or childbirth related deaths per 100,000 women but the current rate is sitting at 210/100,000, which is just a 45% drop.  99% of all maternal deaths occur in low-income and middle-income countries, where resources are limited and access to safe, acceptable, good quality sexual and reproductive health care, including maternity care, is not available to many women during their childbearing year. The most common cause of these maternal deaths are postpartum hemorrhage, postpartum infection, obstructed labors and blood pressure issues – all conditions considered very preventable or treatable with access to quality care and trained birth attendants.

Analysis of reports examined in this paper indicate that “many women globally experience poor treatment during childbirth, including abusive, neglectful, or disrespectful care.” This treatment can further complicate the situation downstream, by creating a disincentive for women to seek care from these facilities and providers in future pregnancies.

The reports and studies that were reviewed to create this report obtained their information from direct observation, interviews with women under care,  and were self-reported by the mothers.  Follow-up surveys were also conducted.

From the qualitative research, investigators were able to classify the mistreatment  into seven categories:

  1. physical abuse
  2. sexual abuse
  3. verbal abuse
  4. stigma and discrimination
  5. failure to meet professional standards of care
  6. poor rapport between women and providers
  7. health system conditions and constraints

The quantitative research revealed two themes: sexual abuse and the performance of unconsented surgical operations.

World Bank Photo Collection http://flickr.com/photos/worldbank/7556637184 shared under a Creative Commons (BY-NC-ND) license

It is no surprise that women’s experiences were negatively impacted by the mistreatment they received during their maternity care treatment period.  Some of the treatment was one on one – from the care provider to the mother, while other inappropriate treatment was on a facility level.

Investigation of the treatment of women during pregnancy and childbirth was conducted because it is known that care by a qualified attendant can significantly impact maternal mortality, but if women are disinclined to seek out appropriate care due to a fear of mistreatment, help is not available or utilized and mortality rates rise.  Removing this obstacle is key to reducing maternal deaths.

Prior experiences and perceptions of mistreatment, low expectations of the care provided at facilities, and poor reputations of facilities in the community have eroded many women’s trust in the health system and have impacted their decision to deliver in health facilities in the future, particularly in low- and middle-income countries Some women may consider childbirth in facilities as a last resort, prioritizing the culturally appropriate and supportive care received from traditional providers in their homes over medical intervention. These women may desire home births where they can deliver in a preferred position, are able to cry out without fear of punishment, receive no surgical intervention, and are not physically restrained. – Bohren, et al.

Women who are mistreated during childbirth obviously reflects a quality of care issue, but also a larger scale- a fundamental human rights issue.  International standards are clear that this is not acceptable.  The researchers encourage the use of their finding to assist in the development of measurement tools that can be used to inform policies, standards and improvement programs.

We must seek to find a process by which women and health care providers engage to promote and protect women’s participation in safe and positive childbirth experiences. A woman’s autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care. – Bohren, et al.

I encourage you to read the study for a thorough review of the research findings.  The information is difficult to fully take in. Additionally, a companion paper  – “Mistreatment of Women in Childbith: Time for Action on this Important Dimension of Violence against Women” provides further information.  The New York Times covered this topic in their June 30th Health Section. The World Health Organization also covered this report and has a statement on this issue, endorsed by over 80 organizations, including Lamaze International.  The WHO also has a list of videos on the topic of abuse and mistreatment of women during pregnancy and childbirth that can be found here.


Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. (2015) The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med 12(6): e1001847. doi:10.1371/journal.pmed.1001847

Jewkes R, Penn-Kekana L (2015) Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women. PLoS Med 12(6): e1001849. doi:10.1371/journal.pmed.1001849

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American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.


Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About Henci Goer

© Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery , , , , , ,

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